NCLEX-RN practice › Safety and Infection Control
NCLEX question: restraint safety and legal standards (SATA)
Safety and Infection Control · Select all that apply · Clinical judgment step: Take action
Client record
Nursing note
- 0200
- Client pulled out NG tube, agitated, not redirectable. Mitts tried without effect. Soft wrist restraints applied.
Provider notified 0205.
A client in the ICU was placed in soft wrist restraints after pulling out a nasogastric tube. Which actions meet safety and legal standards? Select all that apply.
- A. Document less restrictive measures tried and the client's behavior
- B. Tie the restraints to the side rails
- C. Use a quick-release knot
- D. Keep the restraints on until morning rounds regardless of behavior
- E. Monitor circulation, skin and comfort at the intervals set by policy
- F. Obtain a time-limited provider prescription for the restraints
Show the answer and rationales
Answer: A, C, E, F
Restraints require a time-limited prescription, documented alternatives, frequent monitoring, attachment to the bed frame with quick-release knots, and removal at the earliest safe time.
- A. Correct. Documentation must show restraint was a last resort and the ongoing need.
- B. Incorrect. Restraints are tied to the bed frame so that moving the rail does not injure the client.
- C. Correct. Quick-release knots allow rapid removal in an emergency.
- D. Incorrect. Restraints are removed as soon as the client no longer meets criteria.
- E. Correct. Frequent checks prevent injury from restraints.
- F. Correct. Restraints need a prescription that specifies type, reason and time limit; standing or PRN orders are not allowed.
Scoring: select all that apply items on the Next Generation NCLEX use plus/minus scoring. You gain a point for each correct option you choose and lose a point for each incorrect one, with a minimum of zero. This item is worth 4 points.
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